Download Journey Forward Sample Breast Cancer Survivorship Care Plan

SAMPLE
This Survivorship Care Plan will facilitate cancer care following active treatment. It may include
important contact information, a treatment summary, recommendations for follow-up care
testing, a directory of support services and resources, and other information. [1]
Survivorship Care Plan for Breast Cancer
Prepared by:
Martha Trout on 6/17/2012 at Pleasant Valley Cancer Center
General Information
Patient Name
Jane Plummer
Date of birth
6/17/1965
Age at diagnosis
47
Support contact
Tom Plummer
Care team
Hematologist/oncologist
Dr. Howard
General/breast surgeon
Dr. Jones
Radiation oncologist
Dr. Smith
Plastic surgeon
None
Primary care physician
Dr. Wells
OB-GYN
Dr. Innes
Nurse/nurse practitioner
Martha Trout
Mental health/social worker
Susan Green
Coordination of care
Background Information
Family history
None
Genetic testing
Not applicable
Other health concerns
History of cervical cancer at age 29
Echocardiogram or MUGA result
EF = 82%
Additional comments
Had annual mammogram in April 2011 which showed
cyst only. Found lump under arm in August while out
fishing. Jane elected to have bilateral mastectomies due
to her history of cystic lumps in both breast.
© 2013 Journey Forward. All Rights Reserved. Journey Forward thanks Martha Trout MPA, BSN, OCN (R) for her content contribution.
Left breast
Definitive breast surgery
Mastectomy on 1/12/2011
Sentinel node biopsy
No
Axillary dissection
Yes, 1/12/2011
Lymph nodes
13 removed, 3 positive
Tumor type & stage
Infiltrating ductal,
T3 (Tumor is more than 5 cm (2 inches) across),
N2 (Cancer has spread to 4 to 9 lymph nodes under the
arm, or cancer has enlarged the internal mammary
lymph nodes)
Pathologic stage
Stage III (Locally advanced cancer with small, moderate
or large tumor and lymph node involvement)
ER status
Positive
PR status
Positive
HER2 status
Positive
Treatment Plan & Summary
Patient's height
64 in
Pre-treatment
Post-treatment
Patient's weight
127 lb
120 lb
Patient's BSA
1.61 m²
1.57 m²
Patient's BMI
21.8
20.6
Date last menstrual period
9/24/1994
Comments
Due to size of tumor in
breast and painful, matted
nodes under arm, neo
adjuvant selected. During
work-up for possible
clinical trial, a CT scan was
done with no evidence of
metastatic disease.
Regimen
Paclitaxel, Carboplatin
Treatment on clinical trial
No
Therapeutic agents
Skin on left chest wall was
excoriated and needed
dressings with silvadene
until healed.
# cycles
% dose reduction
Paclitaxel
6
0
Carboplatin
6
0
Biologic therapy
Planned: Yes, Administered: Yes
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Ejection fraction
Pre-biologic therapy: 84% (9/2/2010),
Most recent: 82% (12/23/2011)
Biologic therapy treatment dates
9/27/2010 -12/23/2011
Pre-operative chemo administered
Yes
Chemotherapy treatment period
9/27/2010 -1/3/2011
Possible side effects of regimen
Anemia, Cardiac symptoms, Fatigue, Hair loss, Infertility,
Low blood count, Menopause symptoms, Muscle aches,
Nausea/vomiting, Neuropathy
Reconstruction
Planned: No, Completed: No
Radiation therapy
Planned: Yes,
Completed: 3/25/2011, dose: 60 gy
Growth factor given
Yes
Serious toxicities during treatment
Neutropenia
Hospitalization for toxicities
No
Neurotoxicity impairing activities
No
Reason for stopping chemotherapy
Completed therapy
Disease status at end of treatment
Tumor shrinkage as it was given neo-adjuvantly
Endocrine therapy
Anti-estrogen: tamoxifen
Endocrine therapy timing
5 years, starting 4/11/2011
Follow-Up Care
UPON SCREENING, THE PATIENT HAS BEEN DETERMINED TO HAVE THE FOLLOWING ISSUE(S):
Patients – Please consult your health care provider for medical advice specific to you before using any
medications, supplements, or other products, and before beginning any lifestyle program.
Chief patient concern
Concerns about risk of recurrence
Needs/Concerns
Suggested intervention(s)
Concerns about risk of recurrence
Patients need to know that these feelings are normal, and they
won’t cause the cancer to come back.
• Referral for cognitive behavioral therapy or counseling
• Referral to support group, e.g. American Cancer Society
(www.cancer.org, 800-227-2345), Cancer Support Community
(www.wellnessandcancer.org, 888-793-9355)
Fatigue
• Regular physical activity (e.g., walking 20 minutes daily)
• Evaluation for hypothyroidism, anemia, depression
Test
Frequency
Provider to contact
Medical history/physical exam: Yrs 1-3
Every 3 months
Dr. Howard
Medical history/physical exam: Yrs 4,5
Every 6 months
Dr. Howard
Post-treatment mammography
Not needed
Dr. Innes
MRI
Provider decision
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Pelvic examination
Every year
Dr. Innes
Breast self-examination
Every month
Preventive care recommendations
Bone health, Colon cancer screening, Exercise
Comments on follow-up care
Jane worked throughout her treatment, taking time off
only for her surgery. Her two grandsons were her focus
on getting through treatment and surviving as she
didn't want to miss a day with them.
Possible Late Effects of Treatment
You may experience the following effects after cancer treatment.
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Surgery: Numbness, weakness, pain, loss of range of motion (ROM), or arm swelling (lymphedema)
Chemo/Biotherapy: Fatigue, ovarian failure with associated menopausal symptoms, neuropathy,
cognitive dysfunction, weight gain, psychological distress, and sexual dysfunction; increased risk of
leukemia (after anthracycline based therapy), osteoporosis from premature ovarian failure, increased risk
of cardiac dysfunction secondary to anthracycline and/or trastuzumab.
Radiation: Breast pain, fibrosis, telangectasia, atrophy, poor cosmetic outcome.
Hormone therapies:
o
o
Tamoxifen—hot flashes, increased risk of blood clots, uterine cancer, and stroke.
Aromatase inhibitors—increased risk of osteoporosis and fracture.
Reprinted with permission. © 2011 American Society of Clinical Oncology. All rights reserved. www.Cancer.Net.
Life After Cancer Treatment: Managing Fatigue
"If I could stop feeling so tired all the time, I think I'd be fine.
I've started getting used to everything else."—Rosa
Some cancer survivors report that they still feel tired or worn out. In fact, fatigue is one of the most common
complaints during the first year of recovery.
Rest or sleep does not cure the type of fatigue that you may have. Doctors do not know its exact causes. The
causes of fatigue are different for people who are receiving treatment than they are for those who have finished.
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Fatigue during treatment can be caused by cancer therapy. Other problems can also play a part in
fatigue, like anemia (having too few red blood cells) or having a weak immune system. Poor nutrition,
not drinking enough liquids, and depression can also be causes. Pain can make fatigue worse.
Researchers are still learning about what may cause fatigue after treatment.
How long will fatigue last? There is no normal pattern. For some, fatigue gets better over time. Some people,
especially those who have had bone marrow transplants, may still feel energy loss years later.
Some people feel very frustrated when fatigue lasts longer than they think it should and when it gets in the way
of their normal routine. They may also worry that their friends, family, and coworkers will get upset with them if
they continue to show signs of fatigue.
Getting Help
Talk with your doctor or nurse about what may be causing your fatigue and what can be done about it. Ask
about:


How any medicines you are taking or other medical problems you have might affect your energy level
How you can control your pain, if pain is a problem for you
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Exercise programs that might help, such as walking
Relaxation exercises
Changing your diet or drinking more fluids
Medicines or nutritional supplements that can help
Specialists who might help you, such as physical therapists, occupational therapists, nutritionists, or
mental health care providers
Coping with Fatigue
Here are some ideas:
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Plan your day. Be active at the time of day when you feel most alert and energetic.
Save your energy by changing how you do things. For example, sit on a stool while you cook or
wash dishes.
Take short naps or rest breaks between activities.
Try to go to sleep and wake up at the same time every day.
Do what you enjoy, but do less of it. Focus on old or new interests that don't tire you out. For
example, try to read something brief or listen to music.
Let others help you. They might cook a meal, run errands, or do the laundry. If no one offers, ask for
what you need. Friends and family might be willing to help but may not know what to do.
Choose how to spend your energy. Try to let go of things that don't matter as much now.
Think about joining a support group. Talking about your fatigue with others who have had the same
problem may help you find new ways to cope.
End Notes
Note 1: Important caution.
This is a summary document whose purpose is to review the highlights of the cancer chemotherapy treatment plan for
this patient. This does not replace information available in the medical record, a complete medical history provided by
the patient, examination and diagnostic information, or educational materials that describe strategies for coping with
cancer and adjuvant chemotherapy in detail. Both medical science and an individual’s health care needs change, and
therefore this document is current only as of the date of preparation. This summary document does not prescribe or
recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the
independent medical judgment of the treating professional.
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